J. Paediatr. Child Health (1992) 28, 136-140
Review Article Guidelines on tonsillectomy and adenoidectomy B. BENJAMIN Health Commission of New South Wales and the Otolaryngological Society of Australia, Sydney, New South Wales. Australia
Few problems have been the subject of such controversy as surgery for removal of the tonsils and adenoids. Opposing views in the medical literature, publicity in the lay press, sensationalism on television, statistics revealing discrepancies in the incidence of the operation in different areas,' a lack of uniform criteria for the operation and the investigation of economic considerations2 have focused attention on the morbidity and mortality resulting from the operation. In contrast, little has been said about the benefits resulting from the operation. There has been a definite change in attitude by responsible members of the medical profession towards the advisability of the operation, partly due to more 'conservative' assessments as well as doubts and uncertainties as to the indication^.^ Even the most thoughtful and conscientious doctors have diverse views about the operation. The prevailing attitude to tonsil and adenoid surgery is generally derogatory, with many reviews over the last 30 or 40 years emphasizing the lack of .~ doctors, convincing evidence that surgery is b e n e f i ~ i a lSome being aware of the potential anaesthetic, surgical, psychological and immunological risks.5 almost routinely refuse to consider the operation for any patient. Paediatricians especially see their responsible and conscientious role as being to protect children from 'surgical injury'. Some may rationalize that they can therefore denounce unscientific practices and minimize health care costs. They are unlikely to agree to surgery, or even to accept another physician's recommendation for surgery. This group opposes tonsil and adenoid surgery, especially tonsillectomy, almost routinely and automatically reassures the parents that their children will improve as they grow older, no matter what the clinical features. An almost opposite viewpoint IS held by another group, mostly comprising ear, nose and throat surgeons, general practitioners and a small group of paediatricians. This group is apparently convinced, as a result of training and/or personal experience, that tonsil and adenoid surgery will cure or minimize recurring health problems that have required repeated treatment, usually with antibiotics. These physicians do not believe in the philosophy that 'they will grow out of it'; they rely on feedback from parents who state that their children have benefited from the operation. Doctors in this group recommend the removal of tonsils and/or adenoids to parents, even those who previously may have been reluctant about the operation.
Correspondence B Benjamin,The William Bland Centre, 229 Macquarie St, Sydney. NSW 2000, Australia B Benjamin, OBE, DLO. FRACS, FAAP. Head, Department of Otolaryngology Royal Alexandra Hospital for Children. Camperdown. Sydney Accepted for publication 5 July 1991
These opposing views have led many observers to regard the issue as either 'for' or 'against'. But in reality there should be little disagreement nowadays about the indications for removal of the tonsils and adenoids in general, although in an individual case contrary opinions may be expressed. Are too many or too few operations being performed now? In practice, the number of operations for removal of the tonsils and adenoids has decreased dramatically throughout the world, but it is possible that the pendulum could swing too far so that the operation could be delayed unnecessarily or perhaps even denied to some children who would benefit from it.
INDICATIONS FOR TONSILLECTOMY There is now reliable information to support the indications and contra-indications for operation. It has been proven that the frequency of throat infections is definitely reduced in properly selected patients6 Operation for repeated tonsillitis is clearly indicated in a small number of children. Children with obstructive apnoeic attacks and hypoventilation during sleep, sometimes with resultant cardiac decornpensation, undeniably require expert attention. Indications for tonsillectomy are: (1) Repeated attacks of acute tonsillitis (usually children). (2) Hypertrophy causing airways obstruction (chronic or acute on chronic). (3) Chronic tonsillitis (adolescents or adults). (4) Peritonsillar abscess (quinsy). (5) Biopsy excision for suspected new growth.
Repeated attacks of acute tonsillitis A reasonable guide might be more than three attacks of acute tonsillitis a year for 2 years or more, making a minimum of seven attacks in 2 years before consideration should be given to an operation. Other authorities might regard at least seven episodes of acute sore throat in 1 year, five episodes in each of the two preceding years or three in each of the three preceding years as an acceptable guide. In an individual case the advice for or against operation must be modified by such factors as severity of each attack, response to treatment, occurrence of complication, spread of infection to other members of the family, absence from school and the effect on general health. Where repeated infection in the pharyngeal lymphoid tissue warrants operation, adenoidectomy is usually performed along with tonsillectomy unless there is a contra-indication to adenoid-
Tonsillectomy and adenoidectomy
ectomy (e.g. an incompetent palate). As it is unusual for tonsillitis to occur in the first or second year of life, and as it generally requires at least a 2 year history of repeated attacks, operation for repeated tonsillitis is seldom indicated under the age of 4 years. When operation is contemplated in such young children, a second opinion may be in the best interests of the patient. Acute sore throat It is important to know that there is a singular lack of precise definition of acute tonsillitis or of acute ‘sore throat’7 Even in well-conducted studies, there is little correlation of the clinical findings with the causative organisms found after careful microbiological study. Streptococcus pyogenes is cultured in less than half the cases that clinically appear to have acute tonsillitis. In many cases the symptoms and signs of acute sore throat correlate poorly with the presumed or proven aetiological agent, and it is not possible to infer the cause from the clinical picture!a8 A definitive diagnosis of Streptococcal pharyngitis cannot be made on clinical grounds without a positive culture. As there is no direct cause-effect relationship between the isolation of other bacteria from surface throat culture and the features of the illness itself, a bacterial cause cannot be assumed. This makes the precise definition of acute tonsillitis difficult. It appears that besides S. pyogenes, micro-organisms such as adenovirus, Epstein-Barr virus, Herpes simplex virus, mycoplasma and others can be the causative micro-organisms of the clinical entity of acute tonsillitis. Surface cultures in a ‘throat swab’ may not be as reliable as intratonsillar aspiration, which identified other organisms including H. influenzae. It is therefore often difficult to categorize an illness as ’acute tonsillitis’ or ’acute pharyngitis’ or ‘upper respiratory tract infection’. It has been said that ‘we are in abysmal ignorance in understanding the diagnosis and treatment of acute tonsillitis’. Even today the cause and natural history of tonsillitis is insufficiently understood. Not only is there lack of precision in medical terminology but the patient ‘history’ obtained from parents may not really reflect the true state of affairs.6 The history from many parents can be surprisingly unreliable, no matter how particular the physician may be about eliciting this history. The occurrence of repeated attacks of acute sore throat can best be determined by medical examination and parents should present their children to the family doctor to enable the differentiation of recurrent tonsillitis from other acute upper respiratory infections. The term acute sore throat encompasses not only the sore throat that occurs with acute tonsillitis, but also the sore throat that occurs with acute pharyngitis, irrespective of the cause. Differentiation can sometimes be easy. For example, in coryza there is fever, nasal obstruction, nasal discharge and sore throat, and generalized inflammation is seen in the mucous membrane of the nose, oropharynx and the mucous membrane covering the tonsils themselves. Acute tonsillitis may be defined clinically as a condition where inflammation in the oropharynx is mostly confined to the tonsils. The clinical features include acute sore throat, fever, difficulty in swallowing, enlarged tender regional cervical lymph nodes, halitosis and constitutional symptoms such as lethargy, nausea and vomiting. Sometimes there is abdominal pain. The throat should be examined with adequate illumination and a tongue depressor (preferably an angled metal tongue depressor) to determine the local physical signs, the degree of inflammation, redness, oedema, enlargement and exudate. In acute tonsillitis the mucous membrane of the tonsils is initially red and
137
oedematous with generalized inflammation (parenchymatous tonsillitis). As the condition progresses, an acute yellowishwhite exudate is observed in the crypts of the tonsils (follicular tonsillitis). The crypts become filled with debris that is a combination of desquamated epithelium and pus. In some cases coalescence of the follicles occurs with formation of a thin, white, non-confluent patchy membrane that peels away without bleeding (membranous tonsillitis). Although the typical appearance of ‘exudative’ tonsillitis alone is not diagnostic of streptococcal infection, the cause is likely to be a group A 0-haemolytic Streptococcus in cases where the local findings also include intense cellulitis of the uvula and soft palate and haemorrhagic palatal petechiae in the surrounding soft tissues. Tonsillar enlargement Mere enlargement of the tonsils is not necessarily pathological or detrimental to the patient. While swelling due to infection may represent a normal response allowing greater immunological activity, it may predispose to further acute infections if enlargement is due to repeated acute infections and chronic inflammatory oedema, and thus be a relevant physical finding to be considered with other clinical features. It is noteworthy that no significant histopathological changes to correlate with the previous clinical features can be found in tonsils removed at operation. Therefore a surgical audit is not possible. Further, persistent enlargement of the regional cervical lymph nodes, which are commonly palpable in children, is of doubtful significance in most cases. Do enlarged cervical lymph nodes really matter? Are they an indication of tonsillar disease? Possibly the enlargement merely represents physiological hypertrophy rather than a sign of chronic infection. It is not known whether the enlargement is harmful or not. Some of the possible benefits claimed for the operation include: (i) reduction in the frequency of sore throat; (ii)reduction in nose and ear problems; (iii) less absence from school for the child and less time missed from work for the parents; (iv) less cost for medical treatment; (v) reduction in nasal obstruction, which might conceivably improve respiratory function; (vi) improvement in the overall health of the child; and (vii) normalization of craniofacial growth and reduction in hearing impairment. Some of these benefits would have to be categorized as ‘improved quality of life’. Broadly, it is agreed that there is only a small group of children in whom surgery is clearly beneficial for repeated acute sore There is a very much larger group at the other end of the spectrum who clearly do not need, and will never need, operation. Between these two ends of the spectrum lies another group of children whose clinical features are such that removal of the tonsils and adenoids might be appropriate if it could be proven that the operation is efficacious and that the benefits of the operation clearly outweigh the possible risks and the cost. It is for this intermediate group that there is the most disagreement and uncertainty due to a lack of precise data. While many studies have compared certain aspects of the health status of children who have or have not undergone the operation, in most of these studies there has been no control prior to the operation and the two groups have been dissimilar before operation. The comparisons are not statistically valid. A controlled, prospective, statistically valid study is the only worthwhile type6 The few studies performed, however, can be criticized for their choice of patient or the way they have been followed up for statistical evaluation. It is worth noting again that
B. Benjamin
138
no surgical audit on the lymphoid tissue removed at operation is possible. There are no bacteriological or histopathological changes to identify chronically infected tonsils after they have been removed. As yet, it seems quite impossible to measure such variables as the general health of the child, a general feeling of wellbeing, good appetite, lack of cross-infection to other siblings in the family, or a change in school performance.
Peritonsillar abscess This group produces less disagreement. Even so, there are those who do not agree that a single attack of peritonsillar abscess is sufficient to warrant the operation. There would be very few indeed who would not regard two or more attacks of peritonsillar abscess as an indication to justify removal of the tonsils. Antibiotic therapy has lessened the incidence of peritonsillar abscess yet it remains a small but significant problem.’2
Hypertrophy causing airways obstruction The features of airways obstruction- hypoventilation, noisy obstructed breathing, sleepiness during the day and sometimes pulmonary hypertension, cardiomegaly, right heart failure and pulmonary oedema-have been well described, and there are many series documenting this life-threatening The features are always worse during sleep. When cardiac failure occurs it is unresponsive to medical treatment and the airways obstruction must be relieved as a matter or urgency. Obstruction occurs when negative, collapsing, inspiratory pressure exceeds the dilating force of the oropharyngeal muscles. Parents describe very loud snoring or noisy breathing with intermittent obstructive apnoeic attacks during which no air exchange occurs and the child fights for breath. There is a remarkable consistency in the mode of presentation and the response to treatment. There may also be difficulty in swallowing, a hyponasal voice, difficulty in clear articulation, daytime sleepiness, headaches and failure to thrive. In some patients cardiac decompensation occurs, sometimes precipitated by an intercurrent upper respiratory tract infection. In extreme cases the child can present moribund with sudden serious congestive cardiac failure and requiring urgent airways support. The airways obstruction must be relieved as a matter of urgency, either by endotracheal intubation or immediate adenotonsillectomy. Airways obstruction due to hypertrophy of the pharyngeal lymphoid tissue is generally seen in children over the age of 12 months. The difficultly with some patients who might be included in this group is whether partial airways obstruction, insufficient to cause prolonged or chronic hypoventilation, is an indication for operation. There is quite a significant number of children with large tonsils, hyponasal voice, difficulty in clear pronunciation, difficulty in swallowing, persistent snoring and nasal obstruction in whom most clinicians are convinced an operation would be beneficial. Objective and scientific proof of benefit in these cases is difficult however. The clinical features of airways obstruction are usually clear cut. Sleep studies with polygraphic recordings are seldom necessary but in doubtful or complicated cases periods of obstructive apnoea and/or desaturation can be documented.
Biopsy excision Where the clinical features, especially the appearance of the tonsils (e.g. ulceration and unusual unilateral hypertrophy) raises the suspicion of a newgrowth in the absence of other diagnostic features, biopsy excision of the tonsil or tonsils is indicated as a matter of urgency. This, of course, is an uncommon indication.
INDICATIONS FOR ADENOIDECTOMY (1) Adenoid hypertrophy causing severe nasal obstruction and breathing discomfort. (2) Adenoid infection with persistent discharge of mucopurulent material from enlarged or infected adenoids. (3) Possible benefit in repeated acute or chronic ear disease.
Adenoid hypertrophy It has now been proved that where nasal obstruction is with reasonable certainty due to large adenoids, removal of the adenoids results in excellent results for nasal obstruction with the benefits persisting for at least 2 years. 3,6,12 Large adenoids can be demonstrated by visualization with a pharyngeal mirror, by X-ray or under anaesthesia by palpation or inspection with a nasopharyngeal telescope.
Infection of the adenoids Another indication for adenoidectomy is persistent nasal or post-nasal discharge of mucopurulent material from infected and enlarged adenoids. On the other hand, adenoidectomy is not indicated for nasal discharge caused solely by allergic rhinitis or chronic infection in the paranasal sinuses.
Chronic tonsillitis
Possible benefit in ear disease
This group mostly comprises older patients with chronic tonsillitis. There have been very few studies performed. In general terms the indications for operation are repeated acute sore throats, chronic ‘grumbling’, less severe sore throat bad taste in the mouth, bad breath and persistently enlarged regional cervical nodes. Chronic tonsillitis is seldom a paediatric problem. It is seen more often in late teenagers or adults, not in younger children. This group comprises only a small number of the tonsillectomies performed.
For many years adenoidectomy has been considered to be beneficial for patients who have experienced repeated acute or chronic ear disease. However, because of the large number of variables involved, there is as yet no statistically valid trial showing whether adenoidectomy alone has any effect on the rate, severity or duration or recurrent episodes of middle ear infection. Adenoidectomy for ear disease is an unanswered question in the light of present kn0w1edge.l~The so called ‘routine’ removal of the adenoids in the surgical treatment of
Tonsillectomy and adenoidectomy
otitis media with effusion (‘glue ears’) is not considered necessary unless there are other indications for adenoidectomy as outlined above.
MORBIDITY AND MORTALITY Any doctor who recommends tonsil and adenoid surgery must be aware of the possibility of resultant harm to the patient.14 There is no evidence that the removal of tonsils or adenoids induces long-term changes in a patient’s immune status4 Deaths and near deaths occur from anaesthetic ‘accidents’, unskilled anaesthesia, ‘hidden’ blood loss, delayed replacement of blood volume, inadequate postoperative observation, delay and indecision, and indiscriminate use of opiates resulting from an unfamiliarity with paediatric nursing, especially with regard to intravenous infusion and drug dosage. The death rate is highest in small, usually ‘private’, hospitals where facilities, postoperative care and medical supervision may be less than satisfactory. Fatal complications are more likely in children aged 5 years or younger. Analysis of the morbidity and mortality statistics from the operation show very clearly that the operation can be very safe in large teaching hospitals, especially paediatric hospitals that provide skilled, specialized anaesthesia and surgery. Observation in a postoperative recovery ward and continued monitoring after return to the general ward, together with 24 h roundthe-clock resident medical attention allows an absolute minimum of morbidity. Morbidity and mortality can be minimized if the following contra-indications to tonsillectomy and adenoidectomy are observed: (1) Lack of staff a n d facilities to recognize and manage potential complications (the most important factor in the safety of the operation). (2) Recent upper respiratory tract infection (the operation should be postponed if there has been a respiratory tract infection Mithin the previous two weeks). (3) Systemic disorder (e.g. poorly controlled diabetes). (4) A bleeding disorder. (5) Velopharyngeal insufficiency. Adenoidectomy is absolutely contra-indicated in cleft palate, repaired cleft palate, submucous cleft palate, when there is paralysis or paresis of the palate and ‘short’ palate. It may cause or worsen hypernasality with escape of air through the nose during speech. Insufficient attention has been given to this problem in the past.
IMPROVED SAFETY IN TONSIL AND ADENOID SURGERY There is now a greater awareness of the dangers of the operation by both medical and lay people. Parents are better informed yet there is still a need for explanation of and preparation for the operation by the physician. It is, of course, quite erroneous to regard the operation as ‘minor’. Careful pre-operative assessment by the surgeon, and especially the anaesthetist, is essential. Ether has been completely discarded as an anaesthetic agent and endotracheal intubation is universal. The patient must be completely assessed pre-
139
operatively for any possible problems and for the most appropriate anaesthetic technique. Preparation should be made for the potential emotional hazards and pressures for both the patient and the parents, requiring the appropriate co-ordination between the surgeon, the anaesthetist and the nursing staff. Improved surgical techniques include the abandonment of the guillotine operation, better illumination, general anaesthesia with infiltration of supplementary local anaesthesia (with or without adrenaline for analgesia and to decrease blood loss), diathermy control of bleeding, absolute haemostasis in every case, measurement of blood loss, avoidance of ~alicylates,’~ appropriate registrar training in paediatric otolaryngology and better understanding of the problems with anaesthesia. The anaesthetist must be constantly alert during the procedure with appropriate monitoring of vital functions during and after anaesthesia. Facilities to recognize and manage the potential complications are now excellent, especially in paediatric hospitals. Routine intravenous fluids, avoidance of the use of aspirin, observation in a postoperative recovery ward, regular observation of pulse rate for 24 h, prompt replacement of lost circulating blood volume and immediate availability of medical attention are essential. In addition, opiates should not be given to children unless the patient is first seen by a doctor and a thorough assessment of the need for opiates has been made. Anaesthesia for ‘the bleeding tonsil’ requires great expertise. This or any other serious complication demands immediatespecialist consultation. Morbidity and mortality are less when transfer to a paediatric hospital is undertaken early.
CONCLUSION There seems little doubt that some operations continue to be performed without adequate justification and under less than satisfactory conditions. There are no specific or objective criteria on which the success or failure of the operation can be judged. The need for operation to some extent remains a matter of opinion, although authorities generally agree upon the indications and contra-indications. The scientific study of further controlled prospective trials is necessary. The main indication for tonsillectomy in childhood is recurrent acute tonsillitis (e.g. a minimum of three attacks in each of 2 successive years). Operation is rarely justified in children under the age of 4 years. The nature and occurrence of repeated attacks can best be documented by medical attention for each infection. Upper airways obstruction has proved to be an increasingly important reason for operation as the clinical features are more widely known. The potential morbidity and mortality make early recognition mandatory. Chronic tonsillitis is seldom a disorder of younger children. Suspected malignancy and peritonsillar abscess are rare but definite indications for tonsillectomy. Adenoidectomy relieves nasal obstruction and discharge if due to adenoid hypertrophy. It has yet to prove beneficial in middle ear disease. Palatal abnormalities, including ‘short’ palate, are an absolute contraindication to adenoidectomy. The most important contra-indication to these operations is the lack of staff and facilities to recognize and manage potential complications. The death rate is highest when operations are performed in small hospitals.
140
REFERENCES McPherson K., Wennberg J. E., Hovind 0. B., Clifford P. N. Engl. J. Med. 1982; 18: 307-21. Shah C. P., Carr L.M. Tonsillectomies: In dollars and cents. Can. Med. ASSOC. J. 1974.110: 301-3. Rowe L. D. Tonsils and adenoids. When is surgery indicated? Prim. Care 1982; 9: 355-69. Paradise J. L. T and A: Nature of controversy and steps towards its resolution. lflt. J Ped. Oforhinolaryflgol.1979; 1: 201 -1 0. Ytng M. D. Immunological basis of indications for tonsillectomy and adenoidectomy. ACTA Orolaryngol. Suppl. 1988; 454: 279-85. Paradise J. L. ef a/. Efficacy of tonsillectomy for recurrent throat infections in severely affected children: Results of parallel randomized and non-randomizedclinical trials. N. Engl. J. Med. 1984; 310: 674-80. Mandel J. H. Pharyngeal infections. Causes, findings and rnanagement. Postgrad. Med. 1985; 77: 187-93.
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8 Sprinkle P. M.. Ventri R. W. The tonsils and adenoids. Clin. Ofolaryngol. 1977; 2: 153-67. 9 Bluestone C. Status of tonsillectomy and adenoidectomy. Laryngoscope. 1977; 07: 1233-43. 10 Menashe V. D.. Farrehi C. Miller M. Hypoventilation and cor pulmonale due to chronic upper airway obstruction. J. Pediatr. 1965; 67: 198-203. 11 Ahlquist-Rastad J., Hultcrantz E., Svanholm H. Children with tonsillar obstruction: Indicationfor and efficacy of tonsillectomy. ACTA Paediatr. Scand. 1988; 76: 831-5. 12 Gates G. A.. Folbret W. Indications for adeno-tonsillectomy. Arch. Otolaryngol. Head Neck Surg. 1986; 112: 501 -2. 13 Sade J., Luntz M. Adenoidectomy and otitis media. Ann. Otol. Rhino/. Lafyngol. 1991; 100: 226-31. 14 Blum D. J., Nee1 H. 8. Current thinking of tonsillectomy and adenoidectomy. Compr. Ther. 1983; 9: 48-56. 15 Carrick D. G. Salicylates and post-tonsillectomy haemorrhage. J. Laryngol. om/.1984; 98: 803-5.
Review Article Guidelines on tonsillectomy and adenoidectomy B. BENJAMIN Health Commission of New South Wales and the Otolaryngological Society of Australia, Sydney, New South Wales. Australia
Few problems have been the subject of such controversy as surgery for removal of the tonsils and adenoids. Opposing views in the medical literature, publicity in the lay press, sensationalism on television, statistics revealing discrepancies in the incidence of the operation in different areas,' a lack of uniform criteria for the operation and the investigation of economic considerations2 have focused attention on the morbidity and mortality resulting from the operation. In contrast, little has been said about the benefits resulting from the operation. There has been a definite change in attitude by responsible members of the medical profession towards the advisability of the operation, partly due to more 'conservative' assessments as well as doubts and uncertainties as to the indication^.^ Even the most thoughtful and conscientious doctors have diverse views about the operation. The prevailing attitude to tonsil and adenoid surgery is generally derogatory, with many reviews over the last 30 or 40 years emphasizing the lack of .~ doctors, convincing evidence that surgery is b e n e f i ~ i a lSome being aware of the potential anaesthetic, surgical, psychological and immunological risks.5 almost routinely refuse to consider the operation for any patient. Paediatricians especially see their responsible and conscientious role as being to protect children from 'surgical injury'. Some may rationalize that they can therefore denounce unscientific practices and minimize health care costs. They are unlikely to agree to surgery, or even to accept another physician's recommendation for surgery. This group opposes tonsil and adenoid surgery, especially tonsillectomy, almost routinely and automatically reassures the parents that their children will improve as they grow older, no matter what the clinical features. An almost opposite viewpoint IS held by another group, mostly comprising ear, nose and throat surgeons, general practitioners and a small group of paediatricians. This group is apparently convinced, as a result of training and/or personal experience, that tonsil and adenoid surgery will cure or minimize recurring health problems that have required repeated treatment, usually with antibiotics. These physicians do not believe in the philosophy that 'they will grow out of it'; they rely on feedback from parents who state that their children have benefited from the operation. Doctors in this group recommend the removal of tonsils and/or adenoids to parents, even those who previously may have been reluctant about the operation.
Correspondence B Benjamin,The William Bland Centre, 229 Macquarie St, Sydney. NSW 2000, Australia B Benjamin, OBE, DLO. FRACS, FAAP. Head, Department of Otolaryngology Royal Alexandra Hospital for Children. Camperdown. Sydney Accepted for publication 5 July 1991
These opposing views have led many observers to regard the issue as either 'for' or 'against'. But in reality there should be little disagreement nowadays about the indications for removal of the tonsils and adenoids in general, although in an individual case contrary opinions may be expressed. Are too many or too few operations being performed now? In practice, the number of operations for removal of the tonsils and adenoids has decreased dramatically throughout the world, but it is possible that the pendulum could swing too far so that the operation could be delayed unnecessarily or perhaps even denied to some children who would benefit from it.
INDICATIONS FOR TONSILLECTOMY There is now reliable information to support the indications and contra-indications for operation. It has been proven that the frequency of throat infections is definitely reduced in properly selected patients6 Operation for repeated tonsillitis is clearly indicated in a small number of children. Children with obstructive apnoeic attacks and hypoventilation during sleep, sometimes with resultant cardiac decornpensation, undeniably require expert attention. Indications for tonsillectomy are: (1) Repeated attacks of acute tonsillitis (usually children). (2) Hypertrophy causing airways obstruction (chronic or acute on chronic). (3) Chronic tonsillitis (adolescents or adults). (4) Peritonsillar abscess (quinsy). (5) Biopsy excision for suspected new growth.
Repeated attacks of acute tonsillitis A reasonable guide might be more than three attacks of acute tonsillitis a year for 2 years or more, making a minimum of seven attacks in 2 years before consideration should be given to an operation. Other authorities might regard at least seven episodes of acute sore throat in 1 year, five episodes in each of the two preceding years or three in each of the three preceding years as an acceptable guide. In an individual case the advice for or against operation must be modified by such factors as severity of each attack, response to treatment, occurrence of complication, spread of infection to other members of the family, absence from school and the effect on general health. Where repeated infection in the pharyngeal lymphoid tissue warrants operation, adenoidectomy is usually performed along with tonsillectomy unless there is a contra-indication to adenoid-
Tonsillectomy and adenoidectomy
ectomy (e.g. an incompetent palate). As it is unusual for tonsillitis to occur in the first or second year of life, and as it generally requires at least a 2 year history of repeated attacks, operation for repeated tonsillitis is seldom indicated under the age of 4 years. When operation is contemplated in such young children, a second opinion may be in the best interests of the patient. Acute sore throat It is important to know that there is a singular lack of precise definition of acute tonsillitis or of acute ‘sore throat’7 Even in well-conducted studies, there is little correlation of the clinical findings with the causative organisms found after careful microbiological study. Streptococcus pyogenes is cultured in less than half the cases that clinically appear to have acute tonsillitis. In many cases the symptoms and signs of acute sore throat correlate poorly with the presumed or proven aetiological agent, and it is not possible to infer the cause from the clinical picture!a8 A definitive diagnosis of Streptococcal pharyngitis cannot be made on clinical grounds without a positive culture. As there is no direct cause-effect relationship between the isolation of other bacteria from surface throat culture and the features of the illness itself, a bacterial cause cannot be assumed. This makes the precise definition of acute tonsillitis difficult. It appears that besides S. pyogenes, micro-organisms such as adenovirus, Epstein-Barr virus, Herpes simplex virus, mycoplasma and others can be the causative micro-organisms of the clinical entity of acute tonsillitis. Surface cultures in a ‘throat swab’ may not be as reliable as intratonsillar aspiration, which identified other organisms including H. influenzae. It is therefore often difficult to categorize an illness as ’acute tonsillitis’ or ’acute pharyngitis’ or ‘upper respiratory tract infection’. It has been said that ‘we are in abysmal ignorance in understanding the diagnosis and treatment of acute tonsillitis’. Even today the cause and natural history of tonsillitis is insufficiently understood. Not only is there lack of precision in medical terminology but the patient ‘history’ obtained from parents may not really reflect the true state of affairs.6 The history from many parents can be surprisingly unreliable, no matter how particular the physician may be about eliciting this history. The occurrence of repeated attacks of acute sore throat can best be determined by medical examination and parents should present their children to the family doctor to enable the differentiation of recurrent tonsillitis from other acute upper respiratory infections. The term acute sore throat encompasses not only the sore throat that occurs with acute tonsillitis, but also the sore throat that occurs with acute pharyngitis, irrespective of the cause. Differentiation can sometimes be easy. For example, in coryza there is fever, nasal obstruction, nasal discharge and sore throat, and generalized inflammation is seen in the mucous membrane of the nose, oropharynx and the mucous membrane covering the tonsils themselves. Acute tonsillitis may be defined clinically as a condition where inflammation in the oropharynx is mostly confined to the tonsils. The clinical features include acute sore throat, fever, difficulty in swallowing, enlarged tender regional cervical lymph nodes, halitosis and constitutional symptoms such as lethargy, nausea and vomiting. Sometimes there is abdominal pain. The throat should be examined with adequate illumination and a tongue depressor (preferably an angled metal tongue depressor) to determine the local physical signs, the degree of inflammation, redness, oedema, enlargement and exudate. In acute tonsillitis the mucous membrane of the tonsils is initially red and
137
oedematous with generalized inflammation (parenchymatous tonsillitis). As the condition progresses, an acute yellowishwhite exudate is observed in the crypts of the tonsils (follicular tonsillitis). The crypts become filled with debris that is a combination of desquamated epithelium and pus. In some cases coalescence of the follicles occurs with formation of a thin, white, non-confluent patchy membrane that peels away without bleeding (membranous tonsillitis). Although the typical appearance of ‘exudative’ tonsillitis alone is not diagnostic of streptococcal infection, the cause is likely to be a group A 0-haemolytic Streptococcus in cases where the local findings also include intense cellulitis of the uvula and soft palate and haemorrhagic palatal petechiae in the surrounding soft tissues. Tonsillar enlargement Mere enlargement of the tonsils is not necessarily pathological or detrimental to the patient. While swelling due to infection may represent a normal response allowing greater immunological activity, it may predispose to further acute infections if enlargement is due to repeated acute infections and chronic inflammatory oedema, and thus be a relevant physical finding to be considered with other clinical features. It is noteworthy that no significant histopathological changes to correlate with the previous clinical features can be found in tonsils removed at operation. Therefore a surgical audit is not possible. Further, persistent enlargement of the regional cervical lymph nodes, which are commonly palpable in children, is of doubtful significance in most cases. Do enlarged cervical lymph nodes really matter? Are they an indication of tonsillar disease? Possibly the enlargement merely represents physiological hypertrophy rather than a sign of chronic infection. It is not known whether the enlargement is harmful or not. Some of the possible benefits claimed for the operation include: (i) reduction in the frequency of sore throat; (ii)reduction in nose and ear problems; (iii) less absence from school for the child and less time missed from work for the parents; (iv) less cost for medical treatment; (v) reduction in nasal obstruction, which might conceivably improve respiratory function; (vi) improvement in the overall health of the child; and (vii) normalization of craniofacial growth and reduction in hearing impairment. Some of these benefits would have to be categorized as ‘improved quality of life’. Broadly, it is agreed that there is only a small group of children in whom surgery is clearly beneficial for repeated acute sore There is a very much larger group at the other end of the spectrum who clearly do not need, and will never need, operation. Between these two ends of the spectrum lies another group of children whose clinical features are such that removal of the tonsils and adenoids might be appropriate if it could be proven that the operation is efficacious and that the benefits of the operation clearly outweigh the possible risks and the cost. It is for this intermediate group that there is the most disagreement and uncertainty due to a lack of precise data. While many studies have compared certain aspects of the health status of children who have or have not undergone the operation, in most of these studies there has been no control prior to the operation and the two groups have been dissimilar before operation. The comparisons are not statistically valid. A controlled, prospective, statistically valid study is the only worthwhile type6 The few studies performed, however, can be criticized for their choice of patient or the way they have been followed up for statistical evaluation. It is worth noting again that
B. Benjamin
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no surgical audit on the lymphoid tissue removed at operation is possible. There are no bacteriological or histopathological changes to identify chronically infected tonsils after they have been removed. As yet, it seems quite impossible to measure such variables as the general health of the child, a general feeling of wellbeing, good appetite, lack of cross-infection to other siblings in the family, or a change in school performance.
Peritonsillar abscess This group produces less disagreement. Even so, there are those who do not agree that a single attack of peritonsillar abscess is sufficient to warrant the operation. There would be very few indeed who would not regard two or more attacks of peritonsillar abscess as an indication to justify removal of the tonsils. Antibiotic therapy has lessened the incidence of peritonsillar abscess yet it remains a small but significant problem.’2
Hypertrophy causing airways obstruction The features of airways obstruction- hypoventilation, noisy obstructed breathing, sleepiness during the day and sometimes pulmonary hypertension, cardiomegaly, right heart failure and pulmonary oedema-have been well described, and there are many series documenting this life-threatening The features are always worse during sleep. When cardiac failure occurs it is unresponsive to medical treatment and the airways obstruction must be relieved as a matter or urgency. Obstruction occurs when negative, collapsing, inspiratory pressure exceeds the dilating force of the oropharyngeal muscles. Parents describe very loud snoring or noisy breathing with intermittent obstructive apnoeic attacks during which no air exchange occurs and the child fights for breath. There is a remarkable consistency in the mode of presentation and the response to treatment. There may also be difficulty in swallowing, a hyponasal voice, difficulty in clear articulation, daytime sleepiness, headaches and failure to thrive. In some patients cardiac decompensation occurs, sometimes precipitated by an intercurrent upper respiratory tract infection. In extreme cases the child can present moribund with sudden serious congestive cardiac failure and requiring urgent airways support. The airways obstruction must be relieved as a matter of urgency, either by endotracheal intubation or immediate adenotonsillectomy. Airways obstruction due to hypertrophy of the pharyngeal lymphoid tissue is generally seen in children over the age of 12 months. The difficultly with some patients who might be included in this group is whether partial airways obstruction, insufficient to cause prolonged or chronic hypoventilation, is an indication for operation. There is quite a significant number of children with large tonsils, hyponasal voice, difficulty in clear pronunciation, difficulty in swallowing, persistent snoring and nasal obstruction in whom most clinicians are convinced an operation would be beneficial. Objective and scientific proof of benefit in these cases is difficult however. The clinical features of airways obstruction are usually clear cut. Sleep studies with polygraphic recordings are seldom necessary but in doubtful or complicated cases periods of obstructive apnoea and/or desaturation can be documented.
Biopsy excision Where the clinical features, especially the appearance of the tonsils (e.g. ulceration and unusual unilateral hypertrophy) raises the suspicion of a newgrowth in the absence of other diagnostic features, biopsy excision of the tonsil or tonsils is indicated as a matter of urgency. This, of course, is an uncommon indication.
INDICATIONS FOR ADENOIDECTOMY (1) Adenoid hypertrophy causing severe nasal obstruction and breathing discomfort. (2) Adenoid infection with persistent discharge of mucopurulent material from enlarged or infected adenoids. (3) Possible benefit in repeated acute or chronic ear disease.
Adenoid hypertrophy It has now been proved that where nasal obstruction is with reasonable certainty due to large adenoids, removal of the adenoids results in excellent results for nasal obstruction with the benefits persisting for at least 2 years. 3,6,12 Large adenoids can be demonstrated by visualization with a pharyngeal mirror, by X-ray or under anaesthesia by palpation or inspection with a nasopharyngeal telescope.
Infection of the adenoids Another indication for adenoidectomy is persistent nasal or post-nasal discharge of mucopurulent material from infected and enlarged adenoids. On the other hand, adenoidectomy is not indicated for nasal discharge caused solely by allergic rhinitis or chronic infection in the paranasal sinuses.
Chronic tonsillitis
Possible benefit in ear disease
This group mostly comprises older patients with chronic tonsillitis. There have been very few studies performed. In general terms the indications for operation are repeated acute sore throats, chronic ‘grumbling’, less severe sore throat bad taste in the mouth, bad breath and persistently enlarged regional cervical nodes. Chronic tonsillitis is seldom a paediatric problem. It is seen more often in late teenagers or adults, not in younger children. This group comprises only a small number of the tonsillectomies performed.
For many years adenoidectomy has been considered to be beneficial for patients who have experienced repeated acute or chronic ear disease. However, because of the large number of variables involved, there is as yet no statistically valid trial showing whether adenoidectomy alone has any effect on the rate, severity or duration or recurrent episodes of middle ear infection. Adenoidectomy for ear disease is an unanswered question in the light of present kn0w1edge.l~The so called ‘routine’ removal of the adenoids in the surgical treatment of
Tonsillectomy and adenoidectomy
otitis media with effusion (‘glue ears’) is not considered necessary unless there are other indications for adenoidectomy as outlined above.
MORBIDITY AND MORTALITY Any doctor who recommends tonsil and adenoid surgery must be aware of the possibility of resultant harm to the patient.14 There is no evidence that the removal of tonsils or adenoids induces long-term changes in a patient’s immune status4 Deaths and near deaths occur from anaesthetic ‘accidents’, unskilled anaesthesia, ‘hidden’ blood loss, delayed replacement of blood volume, inadequate postoperative observation, delay and indecision, and indiscriminate use of opiates resulting from an unfamiliarity with paediatric nursing, especially with regard to intravenous infusion and drug dosage. The death rate is highest in small, usually ‘private’, hospitals where facilities, postoperative care and medical supervision may be less than satisfactory. Fatal complications are more likely in children aged 5 years or younger. Analysis of the morbidity and mortality statistics from the operation show very clearly that the operation can be very safe in large teaching hospitals, especially paediatric hospitals that provide skilled, specialized anaesthesia and surgery. Observation in a postoperative recovery ward and continued monitoring after return to the general ward, together with 24 h roundthe-clock resident medical attention allows an absolute minimum of morbidity. Morbidity and mortality can be minimized if the following contra-indications to tonsillectomy and adenoidectomy are observed: (1) Lack of staff a n d facilities to recognize and manage potential complications (the most important factor in the safety of the operation). (2) Recent upper respiratory tract infection (the operation should be postponed if there has been a respiratory tract infection Mithin the previous two weeks). (3) Systemic disorder (e.g. poorly controlled diabetes). (4) A bleeding disorder. (5) Velopharyngeal insufficiency. Adenoidectomy is absolutely contra-indicated in cleft palate, repaired cleft palate, submucous cleft palate, when there is paralysis or paresis of the palate and ‘short’ palate. It may cause or worsen hypernasality with escape of air through the nose during speech. Insufficient attention has been given to this problem in the past.
IMPROVED SAFETY IN TONSIL AND ADENOID SURGERY There is now a greater awareness of the dangers of the operation by both medical and lay people. Parents are better informed yet there is still a need for explanation of and preparation for the operation by the physician. It is, of course, quite erroneous to regard the operation as ‘minor’. Careful pre-operative assessment by the surgeon, and especially the anaesthetist, is essential. Ether has been completely discarded as an anaesthetic agent and endotracheal intubation is universal. The patient must be completely assessed pre-
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operatively for any possible problems and for the most appropriate anaesthetic technique. Preparation should be made for the potential emotional hazards and pressures for both the patient and the parents, requiring the appropriate co-ordination between the surgeon, the anaesthetist and the nursing staff. Improved surgical techniques include the abandonment of the guillotine operation, better illumination, general anaesthesia with infiltration of supplementary local anaesthesia (with or without adrenaline for analgesia and to decrease blood loss), diathermy control of bleeding, absolute haemostasis in every case, measurement of blood loss, avoidance of ~alicylates,’~ appropriate registrar training in paediatric otolaryngology and better understanding of the problems with anaesthesia. The anaesthetist must be constantly alert during the procedure with appropriate monitoring of vital functions during and after anaesthesia. Facilities to recognize and manage the potential complications are now excellent, especially in paediatric hospitals. Routine intravenous fluids, avoidance of the use of aspirin, observation in a postoperative recovery ward, regular observation of pulse rate for 24 h, prompt replacement of lost circulating blood volume and immediate availability of medical attention are essential. In addition, opiates should not be given to children unless the patient is first seen by a doctor and a thorough assessment of the need for opiates has been made. Anaesthesia for ‘the bleeding tonsil’ requires great expertise. This or any other serious complication demands immediatespecialist consultation. Morbidity and mortality are less when transfer to a paediatric hospital is undertaken early.
CONCLUSION There seems little doubt that some operations continue to be performed without adequate justification and under less than satisfactory conditions. There are no specific or objective criteria on which the success or failure of the operation can be judged. The need for operation to some extent remains a matter of opinion, although authorities generally agree upon the indications and contra-indications. The scientific study of further controlled prospective trials is necessary. The main indication for tonsillectomy in childhood is recurrent acute tonsillitis (e.g. a minimum of three attacks in each of 2 successive years). Operation is rarely justified in children under the age of 4 years. The nature and occurrence of repeated attacks can best be documented by medical attention for each infection. Upper airways obstruction has proved to be an increasingly important reason for operation as the clinical features are more widely known. The potential morbidity and mortality make early recognition mandatory. Chronic tonsillitis is seldom a disorder of younger children. Suspected malignancy and peritonsillar abscess are rare but definite indications for tonsillectomy. Adenoidectomy relieves nasal obstruction and discharge if due to adenoid hypertrophy. It has yet to prove beneficial in middle ear disease. Palatal abnormalities, including ‘short’ palate, are an absolute contraindication to adenoidectomy. The most important contra-indication to these operations is the lack of staff and facilities to recognize and manage potential complications. The death rate is highest when operations are performed in small hospitals.
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REFERENCES McPherson K., Wennberg J. E., Hovind 0. B., Clifford P. N. Engl. J. Med. 1982; 18: 307-21. Shah C. P., Carr L.M. Tonsillectomies: In dollars and cents. Can. Med. ASSOC. J. 1974.110: 301-3. Rowe L. D. Tonsils and adenoids. When is surgery indicated? Prim. Care 1982; 9: 355-69. Paradise J. L. T and A: Nature of controversy and steps towards its resolution. lflt. J Ped. Oforhinolaryflgol.1979; 1: 201 -1 0. Ytng M. D. Immunological basis of indications for tonsillectomy and adenoidectomy. ACTA Orolaryngol. Suppl. 1988; 454: 279-85. Paradise J. L. ef a/. Efficacy of tonsillectomy for recurrent throat infections in severely affected children: Results of parallel randomized and non-randomizedclinical trials. N. Engl. J. Med. 1984; 310: 674-80. Mandel J. H. Pharyngeal infections. Causes, findings and rnanagement. Postgrad. Med. 1985; 77: 187-93.
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8 Sprinkle P. M.. Ventri R. W. The tonsils and adenoids. Clin. Ofolaryngol. 1977; 2: 153-67. 9 Bluestone C. Status of tonsillectomy and adenoidectomy. Laryngoscope. 1977; 07: 1233-43. 10 Menashe V. D.. Farrehi C. Miller M. Hypoventilation and cor pulmonale due to chronic upper airway obstruction. J. Pediatr. 1965; 67: 198-203. 11 Ahlquist-Rastad J., Hultcrantz E., Svanholm H. Children with tonsillar obstruction: Indicationfor and efficacy of tonsillectomy. ACTA Paediatr. Scand. 1988; 76: 831-5. 12 Gates G. A.. Folbret W. Indications for adeno-tonsillectomy. Arch. Otolaryngol. Head Neck Surg. 1986; 112: 501 -2. 13 Sade J., Luntz M. Adenoidectomy and otitis media. Ann. Otol. Rhino/. Lafyngol. 1991; 100: 226-31. 14 Blum D. J., Nee1 H. 8. Current thinking of tonsillectomy and adenoidectomy. Compr. Ther. 1983; 9: 48-56. 15 Carrick D. G. Salicylates and post-tonsillectomy haemorrhage. J. Laryngol. om/.1984; 98: 803-5.
